Claims & Encounters Operations Management -Process Expert Sr.

Claims & Encounters Operations Management -Process Expert Sr.

Location : This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

For the training period, associates might be required to be in-office more days per week. When reporting to the office, the location is Kansas-OVERLAND PARK, 5901 COLLEGE BLVD STE 275.

It is required that the candidates must reside in the state of Kansas.

Schedule : This position will work a first shift from 8 : 00 am- 5 : 00 pm CST Monday thru Friday.

The Claims & Encounters Operations Management -Process Expert Sr. oversees the administration of claims / encounters processing and operational support functions to ensure compliance with KDHE (Kansas Medicaid). This role manages day-to-day claims / encounters operations, develops workflows for efficiency, and ensures provider and member issues are resolved in alignment with state and federal guidelines.

Primary duties may include, but are not limited to :

• Oversee the end-to-end claims / encounters process, including receipt, adjudication, payment, and performance reporting on claims timeliness, accuracy, backlog and provider payment compliance.
• Serve as the operational liaison with KDHE (Kansas Medicaid), CMS, and internal executive leadership.
• Support and collaborate with the operational teams (Claims Processing, Provider Enrollment Liaison, Member services coordination, Encounters, Care Coordination and Network Management) to resolve provider billing conflicts.
• Researches operations workflow problems and system irregularities.
• Develops, tests, presents process improvement solutions for new systems, new accounts and other operational improvements.
• Develops and leads project plans and communicates project status.
• Provides process direction and decision making for all minor and major project work.
• Provides guidance to process experts.
• May perform duties as a lead when involved with enterprise wide initiatives / projects.
• Ensure timely payment standards are met.
• Maintain claims accuracy standards to reduce denials, reprocessing, and appeals.
• Develop and refine workflows to meet Medicaid performance metrics (e.g., encounter reporting, error reduction).
• Support claims and encounters staff, including training, performance monitoring, and workflow assignments.

Minimum Requirements :

Requires a BA / BS and minimum of 8 years experience in business analysis, process improvement, project coordination in a high-volume managed care operation (claims, customer service, enrollment and billing); or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences :

Ability to analyze workflows, processes, supporting systems and procedures and identifying improvements strongly preferred.

Managed Care Experience in either Health Insurance or with a State Regulator for Medicaid or Medicare strongly preferred.

Broad experience in claims and / or encounters strongly preferred.

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient / member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.